From the College

Cartoon caption contest

Highlights

Studies assess Part D understanding, effects

Medicare Part D has slightly improved medication nonadherence but many beneficiaries are still unclear on the specifics of their benefits, according to two new studies in the April 23/30 Journal of the American Medical Association.

The first study was a population-level survey of 24,234 Medicare beneficiaries conducted in 2006. The participants were asked whether they engaged in cost-related medication nonadherence or spent less on basic needs to afford medicines. Their responses were compared to statistics from 2004 and 2005 (the years before Part D was enacted).

The unadjusted prevalence of nonadherence was 15.2% in 2004, 14.1% in 2005 and 11.5% in 2006. After adjusting for historic changes, the researchers found that nonadherence and spending less on basic needs both decreased significantly from 2005 to 2006 (OR of 0.85 and 0.59, respectively).

Among patients in fair to poor health, there was no significant change in the rates of nonadherence, but those patients did report less need to reduce spending on basic necessities. As a potential explanation, the researchers noted that less healthy beneficiaries would be more likely to fall into the doughnut hole and to have high co-payment costs despite Part D.

An accompanying editorial noted that the generally poor adherence found in the study underscores a problem with Part D—that stand-alone prescription plans have little incentive to improve adherence because it increases drug use. The editorial suggested redesigning of some aspects of Part D, particularly the doughnut hole.

The second study surveyed 1,000 California Part D beneficiaries and found that only 40% of them were aware of the doughnut hole, and those who had reached it were, not surprisingly, more likely to know about it. Beneficiaries who knew about the gap were more likely to take action in response to drug costs but less likely to borrow money or go without necessities. The authors suggested that more education about Part D benefits is in order.

States fighting smoking, but rates holding steady

More states are acting to curb tobacco use, but smoking rates, along with several other cancer risk factors, have remained unchanged in recent years, according to two new reports.

In 2007, five states passed new laws protecting people from secondhand smoke, according to the American Lung Association’s annual update, State Legislated Actions on Tobacco Issues. A total of 21 states plus the District of Columbia now prohibit smoking in workplaces, restaurants and bars. Eight states also increased their tobacco taxes during the year, bringing the average tax to $1.11 per pack, up from $0.45 in 2002. However, only six states fund tobacco control programs at the CDC's recommended level, the report said.

Results of those efforts are not yet apparent, according to the findings of a new report from the American Cancer Society. It found that the percentage of Americans who smoke held steady between 2004 and 2006 at 24% of men and 18% of women. Smoking among high school students has also leveled off, and cigar smoking has been on the rise since 1993. The report noted a correlation between states with high rates of lung cancer and low cigarette taxes.

Americans’ continuing weight gain also raises cancer rates, the report said, noting that the percentage of U.S. adolescents who are overweight has increased from 5% to 17% in the past 20 years. The report also found that mammography rates have stabilized or declined slightly since 2000, and that colonoscopy rates have increased, but not equally among all demographic groups.

Mortality gap widens between the best-off and worst-off

Inequality in U.S. death rates steadily increased between 1983 and 1999 because of stagnating or increasing mortality rates in the worst-off regions, concluded a county-by-county analysis.

Average U.S. life expectancy increased steadily between 1960 and 2000, rising by more than seven years for men (from 66.9 to 74.1 years) and more than six years for women (73.5 to 79.6 years). But not everyone benefited equally.

In the 1980s, the disparity in death rates across different counties began to increase, with the worst-off counties reporting either no decline or an increase in death rates, reported researchers from Harvard University, the University of Washington and the University of California, San Francisco. They looked at data from the National Center for Health Statistics and the Census Bureau.

The difference between life expectancies in the counties in the top 2.5% and bottom 2.5% of mortality rates increased annually between 1983 and 1999. For men, the difference between best and worst increased from 9 years to 11; for women, it rose from 6.7 years to 7.5. Regions with the worst mortality rates included the Deep South, along the Mississippi River, and Appalachia, extending into the southern Midwest and Texas.

Female mortality was affected more heavily due to rising deaths from lung cancer, COPD and diabetes. Those diseases also affected men, but their overall impact was countered by relatively large reductions in cardiovascular death. Instead, men were affected by rising death rates from HIV/AIDS and homicide.

The study reinforces how important it is to monitor health inequalities between different groups to ensure that everyone enjoys gains in life expectancy regardless of economic status, said an editors' summary accompanying the report.

PLoS Medicine, a publication of the Public Library of Science, released the study online.

Women's health

Older women benefit from regular mammograms, study suggests

A recent study suggests that regular mammograms may lead to earlier diagnosis of breast cancer and improved survival in women age 80 or older.

In the population-based analysis, researchers used the Surveillance, Epidemiology, and End Results-Medicare database to identify approximately 13,000 women who were first diagnosed with breast cancer at age 80 or older. In the five years prior to diagnosis, 22% of the women had regular screening mammograms, 29% were screened sporadically and 49% had no mammograms. Breast cancer-specific five-year survival among those who did not get mammograms was 82% compared with 88% among those screened sporadically and 94% for those who got regular mammograms. The study, released early online, will be published in the May 20 Journal of Clinical Oncology.

Patients in the study were 37% less likely to be diagnosed with late-stage cancer for each mammogram obtained. The authors noted that survival from causes other than breast cancer also was associated with regular mammograms, suggesting that healthier patients were more likely to get mammograms.

Studies to date evaluating mammography have excluded women over age 74, the authors noted. They concluded that regular mammography is associated with earlier disease stage in older women and that physicians should consider discussing the potential benefits of regular mammograms with their older patients, particularly those without comorbidities.

Black women have a much smaller chance of developing urinary incontinence than do white women but those that are diagnosed tend to get more severe cases, a recent study found.

The study, published in the April Journal of Urology, found that contrary to common belief, black women do experience stress incontinence. Also, half of the black women (compared with a third of the white women) surveyed by researchers at the University of Michigan said episodes of incontinence resulted in losing urine to the point of noticeably wetting their clothing.

The telephone survey, which included 1,922 black women and 892 white women age 35-64 from three southeastern Michigan counties, found that black women experience urge incontinence twice as often as white women. Black and white women also experience similar rates of conditions associated with incontinence, such as diabetes, constipation and depression.

Gerontology

Antipsychotics pose pneumonia risk for elderly

Elderly people who take antipsychotics have a higher risk of developing pneumonia than those who don’t, a new study suggests.

In a nested case-control analysis, researchers examined 22,944 people aged 65 or older (median study age, 81 years) with at least one antipsychotic prescription. During or after antipsychotic treatment, 543 people were hospitalized with pneumonia; for the analysis, 2,163 case controls were assigned to those 543. Data came from a Dutch database that gathers information from community pharmacies and hospital discharge records. The article was published in the April Journal of the American Geriatrics Society.

Patients currently using antipsychotics had a 60% greater risk of pneumonia, with the greatest risk the first week after starting the drug(s). Atypical antipsychotic users had a higher risk than did users of conventional agents, a difference that couldn’t be explained by dosing differences. Past use wasn’t associated with greater risk. The associations remained when elderly people with a diagnosis of delirium were excluded from the analysis.

Physicians should weigh the possible risks before prescribing antipsychotics to older patients; recent research suggests the drugs are also associated with a higher risk of death in the elderly. If doctors do prescribe antipsychotics, they should monitor elderly patients for swallowing disorders or sedation, the researchers said.

Legal actions

AMA to help physicians enforce BCBS settlement

The American Medical Association (AMA) will begin helping physicians enforce the provisions of a recently settled class action suit against Blue Cross and Blue Shield (BCBS).

The provisions of the settlement, similar to ones AMA and other health organizations filed against many HMOs, address recognition of coding guidelines, prompt payment, medical necessity, and physician credentialing, as well as disclosure of fee schedules, claims procedures and payment policies.

To assist physicians in finding accurate information about the settlement, the AMA offers an interactive on-line map that lists which BCBS plans and subsidiaries have settled, state-specific provisions of the agreement, and the effective dates of the various provisions.

Physicians can find additional information regarding the BCBS settlement, or inquire about assistance with an enforcement issue, online.

Regulatory actions

New type of latex glove seen as less likely to trigger allergic reaction

The FDA last week approved a glove made from a new form of natural rubber latex that appears less likely to stimulate allergic reactions.

The Yulex Patient Examination Glove is derived from the guayule bush, a desert plant native to the Southwestern U.S. While anywhere from 3% to 22% of health care workers are sensitive to traditional latex—which is made from the sap of a rubber tree—available data on guayule latex show it doesn’t produce the same reactions on first exposure, even in those highly allergic to standard latex.

There are no data yet on long-term exposure effects from guayule, so the Yulex glove will carry a warning about the potential for allergic reactions. Traditionally, allergic reactions to latex include skin redness, rash, hives or itching. In more severe cases, reactions can include difficulty breathing, wheezing and shock.

Cimzia approved for Crohn’s disease

Patients should receive one injection of the anti–tumor necrosis factor (TNF) agent every two weeks for the first three injections. If a patient shows benefit from the drug, it can be given once every four weeks. The most common side effects include headache, upper respiratory infections, abdominal pain, injection site reactions and nausea.

Physicians should closely monitor patients on the drug who are at higher risk for serious infections. Certolizumab pegol affects the immune system, so it can lower the body's ability to fight infections like tuberculosis. It may also cause lymphomas and other malignancies. While studies didn’t show an increased risk of tumors from the drug, the trials were relatively short and of modest size, and post-marketing trials will be needed, the FDA said.

Physicians should educate patients taking certolizumab pegol on how to identify an infection and tell them to contact a health care professional at the first sign of infection. The drug should be discontinued immediately if a serious infection develops, the FDA said.

More than 180 people ill after taking supplements with high selenium levels

The CDC is investigating more than 180 reports of illness in people who took dietary supplements that contained hazardous levels of selenium, according to news reports.

The supplements, found in certain lots of Total Body Formula and Total Body Mega Formula, were recalled last month, but illness reports suggest people are still taking it, the April 18 Washington Post reported.

The FDA found the level of selenium was up to 200 times greater than indicated on the labels of the recalled products, with toxic levels found in approximately 1,200 bottles, the Washington Post said. Some bottles also contained up to 17 times the advertised levels of chromium. Health officials are examining a rising number of illnesses in Georgia, Florida, Tennessee, Kentucky, Texas, Louisiana, Michigan, Pennsylvania, Virginia and North Carolina.

Reported symptoms have included hair loss, discolored and painful fingernails, muscle cramps, joint pain, diarrhea and fatigue, with patients becoming sick five to 10 days after first taking the supplements. No one has died, and one person has been hospitalized. The FDA has advised consumers to stop using and discard the Total Body Formula in Tropical Orange and Peach Nectar flavors, and Total Body Mega Formula in Orange/Tangerine flavor.

From the College

Professionalism Charter seeks participants

In 2002, ACP joined the American Board of Internal Medicine (ABIM) and the European Federation of Internal Medicine to launch the Physician Charter for Medical Professionals, a set of standards addressing the ethical issues that are related to the practice of medicine today. The Charter is founded on three principles related to patient welfare, patient autonomy, and social justice. The ABIM Foundation is sponsoring a project to identify individuals and clinical organizations that have demonstrated practices or behaviors of medical professionalism that closely align with the Physician Charter or other medical professionalism models. Examples of initiatives include documents developed by the organization that describe their professional values, education and dialogue to enhance awareness of the principles, and/or methods of measuring and recognizing professionalism. ACP members interested in participating may contact Amy Cunningham, program administrator/analyst at the ABIM Foundation at 215-606-4123 or acunningham@abim.org.

More information about the Charter, ACP’s involvement with the Charter or ACP’s Center for Ethics and Professionalism is online.

Cartoon Caption Contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner.

E-mail all entries to acpinternist@acponline.org by May 8. ACP staff will choose three finalists and post them in the May 13 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the May 20 issue.

Pen the winning caption and win a $50 gift certificate good for any ACP product, program or service.

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright 2008 by the American College of Physicians.

Test yourself

A 54-year-old woman is evaluated for shortness of breath of 3 months' duration and a 4.5-kg (10-lb) weight loss over the preceding 2 months. She has a 35-pack-year smoking history. Following a physical exam and further testing, what is the most appropriate treatment?

Internal Medicine Meeting 2015 Live Simulcast!

Unable to attend the meeting this year? On Saturday, May 2, seven sessions will be streamed live from the meeting. Register for the simulcast and earn CME credit after watching each session. Watch it live or download for later viewing.

Internal medicine physicians are specialists who apply scientific
knowledge and clinical expertise to the diagnosis, treatment, and
compassionate care of adults across the spectrum from health to complex
illness. ACP Internist provides news and information for internists
about the practice of medicine and reports on the policies, products and
activities of ACP. All published material, which is covered by
copyright, represents the views of the contributor and does not reflect
the opinion of the American College of Physicians or any other
institution unless clearly stated.